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Friday, December 10, 2010

Suicide in Hospitals or Why the Joint Commission Drives Me Crazy

If you’ve ever wondered why the Joint Commission [an organization that somehow has managed to become the be-all and end-all for accrediting some 18,000 health care entities in the U.S.] is reviled by many people in health care, you need only look at their latest pronouncement regarding suicide by hospitalized patients. Based on the fact that 827 patient suicides have occurred in hospitals since 1995, the JC [ironically godlike initials] has mandated that hospitals should screen all patients for suicide and depression risk. According to an article in amednews.com, the screening should include the following four steps:

•Check for contraband that could be used to commit suicide.•Alert staff to any warning signs.•Engage the patient at risk and his or her family in formulating a post-discharge plan.•Communicate the suicide risk during hand-off procedures.

Let’s do some math. The 827 hospitalized patient suicides divided by 15 years equals 55 suicides per year. The American Hospital Association reports that in 2009 there were 37,479,709 hospital admissions in the U.S. Thus, the percentage of hospital admissions that resulted in suicide every year is about 55 divided by 37,479,709 or 0.00014%. So to possibly identify 0.00014% of patients, the JC will require hospitals to screen all patients.

I estimate that well over half of the general surgery patients I encounter are on anti-depressant medications, usually more than one. Primary care docs prescribe anti-depressants like Tic Tacs. Are these people really clinically depressed or do they just tell their doctors the feel depressed and receive a prescription?

How is one supposed to ask patients about suicide? How about a woman admitted in labor or a man with appendicitis or a child with pneumonia? I recall a similar mandate a few years ago which involved asking every patient entering the hospital if he wanted to be resuscitated should his heart stop. You can imagine the unsettling effect that had on, let’s say, a woman admitted in labor or a man with appendicitis or the parents of a child with pneumonia. Needless to say, we don’t currently ask most patients whether they want to be resuscitated.

What is going to be the impact of searching all patients for contraband? Maybe hospitals could outsource this component to the TSA. We already have the radiation capability. If you want to commit suicide in a hospital, you don’t need to bring contraband in. You can find things to use or jump out a window.

Knowing the JC as I do, I have no doubt that all of the screening steps will require extensive documentation.

By the way, there are many instances of people committing suicide while under intense psychiatric care both in and out of hospitals. Can all suicides be prevented? I think not.

Should our efforts be better directed at something that occurs more often?